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DESCRIPTION

Raynaud's can occur as a primary or secondary condition. As a primary condition, it is not associated
with any other disease and is often referred to as Raynaud's disease. If Raynaud's symptoms are associated
with another health condition, it is referred to as Raynaud's Phenomenon. Primary Raynaud's is more
common than secondary Raynaud's and usually less severe.

RAYNAUD'S DISEASE

Raynaud's disease is a vascular disorder that affects blood flow to the extremities which
include the fingers, toes, nose and ears when exposed to temperature changes or stress. It was named
after Maurice Raynaud (1834-1881), a French physician who first described it in 1862. Raynaud's
disease is a disorder in which the blood vessels to the fingers and toes (digits) become
abnormally closed off (constricted). The fingers and toes of individuals with Raynaud's disease
change color from white to blue to red, often causing them to feel numb. Raynaud's disease is
sometimes seen with autoimmune diseases, such as rheumatoid arthritis, scleroderma, and lupus, where
the body's immune system turns against itself, causing various symptoms. Other causes of Raynaud's
disease include repeated trauma/vibration, abnormalities in the structure of blood vessels, and
drug injection into one type of blood vessel (arteries).

RAYNAUD'S PHENOMENON

Raynaud's phenomenon (RP), in medicine, is an arthritis-related, vasospastic circulatory disorder
causing discoloration of the hands, fingers, feet, toes, and occasionally other extremities. RP is a
condition resulting in a particular series of discolorations of the fingers and/or the toes after exposure
to changes in temperature (cold or hot) or emotional events. Emotional stress and cold are classic
triggers of the phenomenon, and the discoloration follows a characteristic pattern in time: white, blue and red.

The hands, and sometimes the feet are hypersensitive to cold temperatures.
When the skin is exposed to cold, discoloration occurs because an abnormal spasm of the blood vessels
(the small arteries) that supply the fingers and toes with oxygenated blood. This spasming causes the blood
vessels to become abnormally closed off (constrict) resulting in a diminished oxygenated blood supply
to the local tissues and a noticeable color change in the affected tissues.

Initially, the digit(s) involved turn white because of the diminished blood supply. The digit(s) then
turn blue because of prolonged lack of oxygen. Finally, the blood vessels reopen, causing a local
"flushing" phenomenon, which turns the digit(s) red. This three-phase color sequence (white to blue
to red), most often upon exposure to cold temperature, is characteristic of RP. This condition can
also cause nails to become brittle with longitudinal ridges.

Raynaud's phenomenon most frequently affects women, especially in the second, third, or fourth decades
of life. People can have Raynaud's phenomenon alone or as a part of other rheumatic diseases. When
it occurs alone, it is referred to as "Raynaud's disease" or primary Raynaud's phenomenon. When it
accompanies other diseases, it is called secondary Raynaud's phenomenon.

RP comprises both Raynaud's disease (primary Raynaud's), where the phenomenon is idiopathic, and
Raynaud's syndrome (secondary Raynaud's), where it is caused by some other instigating factor.
Measurement of hand-temperature gradients is one tool used to distinguish between the primary and
secondary forms. It is possible for the primary form to progress to the secondary form.

The condition causes painful, pale, cold extremities. This can often be distressing to those who are
not diagnosed, and sometimes it can be obstructive. If someone with Raynaud's is placed in too cold
a climate, it could potentially become dangerous.

Unilateral Raynaud's, or that which is present only in the hands or feet, is almost certainly
secondary, as primary Raynaud's is a systemic condition. However, a patient's feet may be affected
without him or her realizing it. In pregnancy, this sign normally disappears due to increased surface
blood flow.

Over time, the condition may result in a general shrinkage of the affected area. Ultimately, ulcers
may form, damaging the tissues and resulting in chronic infection under and around the fingernails and
toenails. In severe cases, gangrene may result from prolonged and persistent contraction of the arteries.

ABOUT GANGRENE

Gangrene is a condition in which body tissues die, and ultimately decay, as a result of
inadequate oxygen supply. It can affect any body part, but most frequently affects extremities such as the toes,
feet, fingers, hands, and arms. Gangrene of the internal organs is especially dangerous.

Symptoms of Raynaud's phenomenon depend on the severity, frequency, and duration of the blood-vessel spasm.
Most patients with mild disease only notice skin discoloration upon cold exposure.

The vasospasm which occurs during a Raynaud's attack usually lasts 15 minutes but can range from just one
minute to several hours. Pain, swelling, tingling, throbbing, numbness, and discoloration can all
occur in the affected area. Fingers and toes are the most common site of Raynaud's phenomenon. In Raynaud's
disease (primary), both hands and both feet are commonly affected. Besides fingers and toes, Raynaud's can
affect the ears, nose, lips, knees, and nipples.

DISCOLORATION

Raynaud's phenomenon is characterized by a pale-blue-red sequence of color changes of the digits,
most commonly after exposure to cold. The symptoms include several cyclic color changes:

When exposed to cold temperatures, the blood supply to the fingertips, toes, nose, and earlobes of
Raynaud's disease patients is reduced and the skin turns pale or white (called pallor) and becomes
cold and numb.

When the oxygen supply is depleted, the skin color turns blue (called cyanosis).

These events are episodic and when the episode subsides, or the area is warmed, blood returns to the area
and the skin color turns red (rubor) and then back to normal, often accompanied by swelling and tingling.

These symptoms are thought to be due to reactive hyperemias of the areas deprived of blood flow.
All three color changes are present in classic Raynaud's disease. However, some patients do not see all
of the color changes in all outbreaks of this condition.

Figure A shows the normal digital arteries with normal blood flow to the fingers. The inset images show
cross-sections of a normal artery.

Figure C shows narrowed digital arteries, causing blocked blood flow and purple discoloration of the
fingertips. The inset images show cross-sections of a narrowed artery blocking the flow of blood.

OTHER SYMPTOMS & COMPLICATIONS

Symptoms of RP depend on the severity, frequency, and duration of the blood vessel spasm. Most patients
with mild disease only notice skin discoloration upon cold exposure. They may also experience mild
tingling and numbness of the involved digit(s) that will disappear once the color returns to normal.
When the blood-vessel spasms become more sustained, the sensory nerves become irritated by the lack
of oxygen and can cause pain in the involved digit(s). Rarely, poor oxygen supply to the tissue can
cause the tips of the digits to ulcerate. Severe Raynaud's disease can result in skin ulcers. This
complication is more common in people who have both scleroderma and Raynaud's disease. Ulcerated digits
can become infected. With continued lack of oxygen, gangrene of the digits can occur.

Less common areas of the body that can be affected by RP include the nose, ears, and tongue. While these
areas rarely develop ulcers, they can be associated with a sensation of numbness and pain.

People with Raynaud's disease may have more noticeable small blood vessels (capillaries) into their
fingers and toes where the nail plate meets the skin of the finger (proximal nail fold), particularly
in people who also have an autoimmune disease.

Patients with secondary RP can also have symptoms related to their underlying diseases. RP is the initial
symptom of 70 percent of patients with scleroderma, a skin and joint disease. Other rheumatic diseases frequently
associated with RP include systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's syndrome.

It is normal for the body to keep its vital inner organs warm by limiting blood flow to the arms,
legs, fingers, and toes. The body naturally does this in response to a long period of cold. This
response can cause frostbite. In people with Raynaud's, the response to cold is quicker and stronger.
The response can be triggered by mild or short-lived changes in temperature, such as:

Taking something out of the freezer.

Temperatures that dip below 60°F.

In people with Raynaud's, blood flow is more strongly reduced in response to cold temperatures than in
people without the disorder. When Raynaud's is severe (which is uncommon), exposure to cold for as little
as 20 minutes can cause major tissue damage.

The blood vessels of people with Raynaud's also physically overreact to stressful emotions. It is normal
during times of psychological stress for the body to release hormones that narrow its blood vessels.
But for people with Raynaud's, this squeezing of blood vessels is stronger. This results in less blood
reaching fingers, toes, and sometimes other extremities.

Attacks usually last about 15 minutes. They can last less than a minute or as long as several hours. Attacks
can occur daily or weekly. Sometimes attacks affect only one or two fingers or toes. Different areas may be
affected at different times. Attacks can cause sores or tissue death (gangrene) in people with severe
secondary Raynaud's. However, severe Raynaud's is very uncommon.

CAUSES

The causes of primary and secondary Raynaud's phenomenon is unknown and is not completely understood,
although abnormal nerve control of blood-vessel diameter causing constriction of blood vessels
and nerve sensitivity to cold and excessive stress are suspected of being involved and as being
contributing factors. Some researchers are also studying if genetics is related to Raynaud's phenomenon.
When no cause can be found, the disorder is called primary Raynaud's. When a cause can be found, the
disorder is called secondary Raynaud's.

Raynaud's phenomenon occurs because of vasospasm of blood vessels temporarily limiting blood flow to
affected tissues. The characteristic color
changes of the digits are in part related to initial blood-vessel narrowing due to spasm of the tiny muscles
in the wall of the vessels, followed by sudden opening (dilation), as described above. The small arteries
of the digits can have microscopic thickness of their inner lining, which also leads to abnormal narrowing
of the blood vessels.

CONDITIONS ASSOCIATED WITH RAYNAUD'S PHENOMENON

Secondary Raynaud's phenomenon has been linked to many different medical or workplace conditions such as:

Diseases that damage blood vessels or the nerves that control the function of blood vessels
in the hands and feet.

Repetitive actions that damage the nerves that control blood vessels in the hands and feet.

Pulmonary hypertension (high blood pressure in the arteries of the lungs.

Mixed connective tissue disease.

Dermatomyositis.

Polymyositis.

Buerger's disease.

Tissue trauma from frostbite or injury to hands or feet from surgery or other causes.

Repetitive stress and actions, such as using vibrating tools, typing or playing the piano for
long periods of time.

Exposure to certain chemicals at work can cause a scleroderma-like illness that is linked to Raynaud's.

Smoking. Nicotine in cigarette smoke also can make you more prone to developing Raynaud's.

Several medicines are linked to secondary Raynaud's, including:

Migraine headache medicines that contain ergotamine.

Beta blockers used for blood pressure problems, such as propranolo (Inderal). Propranolol is in
a group of drugs called beta-blockers. Beta-blockers affect the heart and circulation (blood flow through
arteries and veins). Propranolol is used to treat tremors, angina (chest pain) and hypertension (high blood
pressure).

Estrogens without additional progesterone.

Certain cancer medications, such as bleomycin (Bleoxane) used in cancer treatment.

Some over-the-counter (OTC) cold or allergy remedies.

PREVALENCE OF RAYNAUD'S PHENOMENON

The National Institute of Arthritis and Musculoskeletal and Skin Conditions estimates that 5 to 10
percent of the United States population is affected by Raynaud's phenomenon. Seventy-five percent of
primary Raynaud's cases involve women 15 to 40 years old. 85 to 95 percent of people with scleroderma
or MCTD also have Raynaud's phenomenon. One third of lupus patients have Raynaud's symptoms.

POINTS OF INTEREST ABOUT RAYNAUD'S PHENOMENON

Keeping warm is the key to managing Raynaud's phenomenon, even if that means wearing gloves when you
are inside the house.

Running warm water over affected cold areas can offer relief.

Remaining calm is essential.

Raynaud's can begin at any age.

DISEASE VS PHENOMENON

It is important to distinguish Raynaud's disease from Raynaud's phenomenon. In order to diagnose these
two forms of Raynaud, your health care provider may look for signs of arthritis or vasculitis and
conduct a number of laboratory tests. See more about diagnosis under the Treatment section below.

Primary Raynaud's (Disease): Raynaud's disease (or "Primary Raynaud's") is diagnosed if the symptoms
occur only by themselves and are not accompanied by other diseases. Primary Raynaud's often develops in
young women in their teens and young adulthood. This form of Raynaud's is thought to be at least partly
hereditary, although specific genes have not yet been identified. Some refer to Primary Raynaud's disease
as being allergic to the cold.

The most common causes are connective tissue disorders such as systemic lupus erythematosus,
scleroderma/systemic sclerosis/CREST syndrome, arthritis and many others.

Other disorders that can be causes include carpal tunnel syndrome and obstructive arterial disease.

Medications that can be causes include beta-blockers and ergotamine.

In contrast to the disease form, this form of Raynaud can progress to necrosis or gangrene of the fingertips.

Patients with secondary RP can also have symptoms related to their underlying diseases. RP is the initial
symptom of 70 percent of patients with scleroderma, a skin and joint disease. Other rheumatic diseases
frequently associated with RP include systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's
syndrome.

About 3 out of 4 cases of primary Raynaud's occur in younger to middle-aged women between the ages of 15
and 40 years, although the reason is unknown. When it affects men, it is usually seen in middle age or
later in life. A Framingham study found the incidence in men was 5.8 percent and 9.6 percent of women
suffered from it.

Raynaud's disease is seen in 20 percent of people with lupus.

People in colder climates are also more likely to develop Raynaud's than people in warmer areas.

There is a familial component to primary Raynaud's, and presentation is typically before two.

It is important to realize that Raynaud's can herald these diseases by periods of more than 20 years
in some cases, making it effectively their first presenting symptom. This can be the case in the CREST
syndrome, of which Raynaud's is a part.

PREVENTION

Patients with Raynaud's disease are advised to keep warm by wearing gloves and socks. They should
also avoid stress, medicines that can constrict blood vessels such as decongestants and touching
cold objects. Patients are also advised to avoid foods and activities that may constrict blood vessels
such as drinking caffeinated drinks and smoking. Avoiding artificially cold environments, such as
refrigerated or highly air conditioned spaces, can also help prevent episodes from occurring.

DIAGNOSIS & TREATMENT

PATHOPHYSIOLOGY

Raynaud disease is an exaggeration of vasomotor responses to cold or emotional stress. More specifically,
it is a hyperactivation of the sympathetic system causing extreme vasoconstriction of the peripheral
blood vessels, leading to tissue hypoxia. Chronic, recurrent cases of Raynaud phenomenon can result
in atrophy of the skin, subcutaneous tissues, and muscle. It can also rarely cause ulceration and
ischemic gangrene.

DIAGNOSIS

Health care providers use the patient's history of symptoms, a physical exam, and diagnostic tests to rule out other
conditions that might act like Raynaud's. A careful patient history will often reveal whether the condition
is primary or secondary. Once this has been established, investigations are largely to identify or exclude
possible secondary causes.

A physical examination by your health care provider will look for physical symptoms related to Raynaud's
phenomenon such as blueness or pallor to the skin and skin ulcers.

COLD STIMULATION TEST

To help diagnose Raynaud's, a health care provider may do a cold simulation test. In patients with the
characteristic sequence of skin-color changes of the digits upon cold exposure, diagnosing RP is not
difficult. This test can trigger an attack that is typical of the disorder. They also may do tests for
inflammatory disorders that damage blood vessels or nerves. Having these conditions along with Raynaud's
symptoms makes it more likely that a patient has secondary Raynaud's disease.

In the cold simulation test, temperature sensors are taped to the fingers of the hand. The hand is then
briefly exposed to the cold, usually by dunking it in ice water. If the patient likely has Raynaud's,
it will take more than the normal time for the finger temperature to return to what it was at the start
of the test.

Digital Artery Pressure: Pressures are measured in the digital arteries before and after cooling the
hands. A drop of 15mmHg or more is diagnostic.

Doppler Ultrasound: A doppler ultrasound may be used to assess flow.

NAILFOLD CAPILLAROSCOPY

Health care providers also may do a test called a nailfold capillaroscopy. Sometimes, certain patterns
in the tiny blood vessels (capillaries) adjacent to the fingernails of patients with RP can be seen using
a magnifying viewing instrument. Abnormal nail-fold capillary patterns can suggest the possibility of an
associated rheumatic condition. For this test, the practitioner puts a drop of oil on the skin at the base
of the fingernail and then looks at it under a microscope. If the practitioner sees abnormal looking blood
vessels, this suggests an inflammatory disorder such as scleroderma.

BLOOD TESTS

There is, however, no single blood test to help the health care provider to confirm the diagnosis.
The practitioner can order certain blood tests (for example, sedimentation rate, rheumatoid factor,
antinuclear antibody, thyroid hormone levels, and protein levels) to exclude associated rheumatic
diseases and thyroid disorders. Typically patients with Raynaud's phenomenon that is a manifestation
of a rheumatic disease have elevated blood sedimentation rates and antinuclear antibodies. Furthermore,
capillary nail fold abnormalities can frequently be found as described above.

Complete Blood Count (CBC): This test can reveal a normocytic anemia suggesting the anemia of
chronic disease or renal failure.

Urea & Electrolytes: This test can reveal renal impairment.

Thyroid Function Tests: This can reveal hypothyroidism.

Erythrocyte Sedimentation Rate (Sedrate or ESR), C-Reactive Protein (CRP) & Antinuclear Antibody Test (ANA):
These routinely used tests looks for antibodies for rheumatoid factor and may reveal causative illness
or a generalized inflammatory process or to rule out other arthritis-related conditions.

ESR & CRP TESTS

The ESR is an easy, inexpensive, non-specific test that has been used for many years to help diagnose
conditions associated with acute and chronic inflammation, including infections, cancers, and autoimmune
diseases. ESR is said to be non-specific because increases do not tell the practitioner exactly where the
inflammation is in your body or what is causing it, and also because it can be affected by other
conditions besides inflammation. For this reason, ESR is typically used in conjunction with other tests.

ESR is helpful in diagnosing two specific inflammatory diseases, temporal arteritis and polymyalgia
rheumatica. A high ESR is one of the main test results used to support the diagnosis. It is also used
to monitor disease activity and response to therapy in both of these diseases.

A health care provider usually orders an ESR test (along with others) to evaluate a patient who has
symptoms that suggest polymyalgia rheumatica or temporal arteritis, such as headaches, neck or shoulder
pain, pelvic pain, anemia, unexplained weight loss, and joint stiffness. There are many other conditions
that can result in a temporary or sustained elevation in the ESR.

Since ESR is a non-specific marker of inflammation and is affected by other factors, the results must
be used along with the health care provider's other clinical findings, the patient's health history, and results from
other appropriate laboratory tests. If the ESR and clinical findings match, the practitioner may be able
to confirm or rule out a suspected diagnosis. A single elevated ESR, without any symptoms of a specific
disease, will usually not give the health care provider enough information to make a medical decision.

Before doing an extensive workup looking for disease, a health care provider may want to repeat the
ESR test after a period of several weeks or months. If a health care provider already knows the patient
has a disease like temporal arteritis (where changes in the ESR mirror those in the disease process),
she may order the ESR at regular intervals to assist in monitoring the course of the disease. In the
case of Hodgkin's disease, for example, a sustained elevation in ESR may be a predictor of an early
relapse following chemotherapy.

ESR Test Results - A standard reference range is not available for this test. Because reference values
are dependent on many factors, including patient age, gender, sample population, and test method, numeric
test results have different meanings in different labs. Your lab report should include the specific
reference range for your test. It is strongly recommended that you discuss your test results
with your health care provider. Health care providers do not base their decisions solely on ESR results.
You can have a normal result and still have a problem. Moderately elevated ESR occurs with inflammation,
but also with anemia, infection, pregnancy, and old age. A very high ESR usually has an obvious cause,
such as a marked increase in globulins that can be due to a severe infection. The practitioner will use
other follow-up tests, such as cultures, depending on the patient's symptoms. Persons with multiple
myeloma or Waldenstrom's macroglobulinemia (tumors that make large amounts of immunoglobulins) typically
have very high ESRs even if they do not have inflammation. As noted before, polymyalgia rheumatica and
temporal arteritis may also have very high ESRs. A rising ESR can mean an increase in inflammation or a
poor response to a therapy; a decreasing ESR can mean a good response. Although a low ESR is not usually
important, it can be seen with polycythemia, with extreme leukocytosis, and with some protein abnormalities.
Some changes in red cell shape (such as sickle cells in sickle cell anemia) also lower the ESR.

ESR and C-reactive protein (CRP) are both markers of inflammation. Generally, ESR does not change as
rapidly as does CRP, either at the start of inflammation or as it goes away. CRP is not affected by as
many other factors as is ESR, making it a better marker of inflammation. However, because ESR is an easily
performed test, many health care providers still use ESR as an initial test when they think a patient
has inflammation.

If the ESR is elevated, it is typically a result of globulins or fibrinogens. Your health care provider
may then order a fibrinogen level (a clotting protein that is another marker of inflammation) and a serum
protein electrophoresis to determine which of these (or both) is causing the elevated ESR. Females tend
to have higher ESR, and menstruation and pregnancy can cause temporary elevations.

In a pediatric setting, the ESR test is used for the diagnosis and monitoring of children with rheumatoid
arthritis or Kawasaki's Disease.

Drugs such as dextran, methyldopa (Aldomet), oral contraceptives, penicillamine procainamide, theophylline,
and vitamin A can increase ESR, while aspirin, cortisone, and quinine may decrease it.

ANA TEST

The ANA test is ordered to help screen for autoimmune disorders and is most often used as one of the
tests to diagnose systemic lupus erythematosus (SLE). Depending on the patient's symptoms and the
suspected diagnosis, ANA may be ordered along with one or more other autoantibody tests. Other laboratory
tests associated with presence of inflammation, such as erythrocyte sedimentation rate (ESR) and/or
C-reactive protein (CRP) may also be ordered. ANA may be followed by additional tests that are considered
subsets of the general ANA test and that are used in conjunction with the patient's clinical history to
help rule out a diagnosis of other autoimmune disorders.

The ANA test is ordered when a patient shows signs and symptoms that are associated with SLE or another
autoimmune disorder. It may also be ordered when a patient has been diagnosed with an autoimmune disorder
and the health care provider suspects that the patient may have developed an additional autoimmune disorder.
Patients with autoimmune disorders can have a wide variety of symptoms such as low-grade fever, joint pain,
fatigue, and/or unexplained rashes that may change over time.

ANA Test Results - ANA tests are performed using different assays (indirect immunofluorescence
microscopy or by enzyme-linked immunoabsorbant assay - ELISA) and results are reported as a titer with
a particular type of immunofluroscence pattern (when positive). Low-level titers are considered negative,
while increased titers, such as 1:320, are positive and indicate an elevated concentration of antinuclear
antibodies. ANA shows up on indirect immunofluorescence as fluorescent patterns in cells that are fixed
to a slide that is evaluated under a microscope. Different patterns are associated with a variety of
autoimmune disorders. Some of the more common patterns include:

An example of a positive result might be: "Positive at 1:320 dilution with a homogenous pattern." A positive
ANA test result may suggest an autoimmune disease, but further specific testing is required to assist in
making a final diagnosis. ANA test results can be positive in people without any known autoimmune disease.
While this is not common, the frequency of a false positive ANA result increases as people get older. Also,
ANA may become positive before signs and symptoms of an autoimmune disease develop, so it may take time to
tell the meaning of a positive ANA in a person who does not have symptoms. Most positive ANA results do not
have significance, so health care providers should reassure their patients but should also still be vigilant
for development of signs and symptoms that might suggest an autoimmune disease. About 95 percent of SLE
patients have a positive ANA test result. If a patient also has symptoms of SLE, such as arthritis, a rash,
and autoimmune thrombocytopenia, then he probably has SLE. In cases such as these, a positive ANA result
can be useful to support SLE diagnosis. Two subset tests for specific types of autoantibodies, such as
anti-dsDNA and anti-SM, may be ordered to help confirm that the condition is SLE.

A positive ANA can also mean that the patient has drug-induced lupus. This condition is associated with
the development of autoantibodies to histones, which are water soluble proteins rich in the amino acids
lysine and arginine. An anti-histone test may be ordered to support the diagnosis of drug-induced lupus.

Other conditions in which a positive ANA test result may be seen include:

Sjogren's Syndrome: Between 40-70 percent of patients with this condition have a positive ANA test
result. While this finding supports the diagnosis, a negative result does not rule it out. The health care
provider may want to test for two subsets of ANA: Anti-SS-A (Ro) and Anti-SS-B (La). The frequency of
autoantibodies to SSA in patients with Sjogren's can be 90 percent or greater.

Scleroderma: About 60-90 percent of patients with scleroderma have a positive ANA finding. In
patients who may have this condition, ANA subset tests can help distinguished two forms of the disease,
limited versus diffuse. The diffuse form is more severe. Limited disease is most closely associated with
the anticentromere pattern of ANA staining (and the anticentromere test), while the diffuse form is
associated with autoantibodies to the anti-Scl-70.

A positive result on the ANA also may show up in patients with Raynaud's disease, rheumatoid arthritis,
dermatomyositis, mixed connective tissue disease, and other autoimmune conditions.

A practitioner must rely on test results, clinical symptoms, and the patient's history for diagnosis.
Because symptoms may come and go, it may take months or years to show a pattern that might suggest SLE or
any of the other autoimmune diseases. A negative ANA result makes SLE an unlikely diagnosis. It usually
is not necessary to immediately repeat a negative ANA test; however, due to the episodic nature of
autoimmune diseases, it may be worthwhile to repeat the ANA test at a future date. Aside from rare cases,
further autoantibody (subset) testing is not necessary if a patient has a negative ANA result.

Some drugs and infections as well as other conditions mentioned above can give a false positive result
for the ANA test. About 3-5 percent of Caucasians may be positive for ANA and it may reach as high as
10-37 percent in healthy individuals over the age of 65. Some medications may bring on a condition that
includes SLE symptoms, called drug-induced lupus. When the drugs are stopped, the symptoms usually go
away. Although many medications have been reported to cause drug-induced lupus, those most closely
associated with this syndrome include hydralazine, isoniazid, procainamide, and several anticonvulsants.

OTHER TESTS

The health care provider can also perform certain maneuvers with the patient's extremities to exclude
pinched blood vessels that can produce symptoms that mimic RP, such as in thoracic outlet syndrome.

Specialists may be called in for consultation on your case. A rheumatologist is a health care practitioner
who specializes in treating disorders of the joints, bones, and muscles. Often, a rheumatologist diagnoses
and treats patients with Raynaud's, but internists and family practice practitioners also are able to
diagnose and treat Raynaud's.

CONVENTIONAL MEDICAL TREATMENT

There is no cure for primary or secondary Raynaud's, but many measures can reduce the number or intensity of
attacks. Conventional medical treatment of Raynaud's phenomenon is focused on prevention - preventing future Raynaud's
attacks and preventing permanent tissue damage. Treatment of Raynaud's phenomenon involves protection of
the digits, medications, and life style changes such as avoiding emotional stresses, smoking, cold temperature,
and tools that vibrate the hands. Treatment can include:

Keeping warm and protecting against exposure to cold.

Stress management.

Relaxation techniques.

Stop smoking, if you are a smoker.

Exercise to increase circulation.

Treatment for the disease or condition that may help cause secondary Raynaud's.

Surgery for tissue damage that some people with secondary Raynaud's develop, but rarely needed.

MEDICATIONS & DRUG THERAPY

Medications used to treat Raynaud's symptoms include calcium channel blockers, catecholamine deceptors,
vasodilators, and smooth muscle relaxers. Most of the medicines used to treat people with
Raynaud's are given to improve blood flow to the extremities.

Patients with persistent or bothersome symptoms may be helped by taking oral medications that open
(dilate) blood vessels. Drug treatment is normally with a calcium channel blocker (calcium antagonists),
frequently nifedipine to prevent arterioconstriction and to treat hypertension. Like all drugs, this
can have side effects. It has the usual common side effects of headache, flushing, and ankle edema; but
normally result in not needing to stop the drug. Calcium channel-blockers help limit the number and
severity of attacks in about 2 out of 3 patients with Raynaud's. These medicines include calcium
channel-blockers, such as:

Nifedipine (Procardia, Adalat, Procardia).

Nicardipine (Cardene).

Amlodipine (Norvasc).

Diltiazem (Cardizem, Dilacor).

Felodipine (Plendil).

Isradipine (Dynacirc, Prescal).

Angiotensin II receptor antagonists used in blood pressure treatment (often Losartan) and
others, such as methyldopa (Aldomet) and prazocin (Minipress) may be used in treatment of Raynaud's to reduce
the frequency and severity of attacks, possibly better than nifedipine. Recent research and evidence has
shown that the blood-pressure drug losartan (Cozaar, Hyzaar) can reduce the severity of episodes of RP
possibly more than nifedipine.

Alpha-1 adrenergic blockers such as prazosin (Minipress, Vasoflex, Hypovase) can be used to control Raynaud's
vasospasms under supervision of a health care provider. In a study published in the November 8, 2005 issue
of Circulation, sildenafil (Viagra) improved both microcirculation and symptoms in patients with secondary
Raynaud's phenomenon resistant to vasodilatory therapy. The authors, led by Dr Roland Fries
(Gotthard-Schettler-Klinik, Bad Schönborn, Germany), report: "In the present study, capillary blood flow
was severely impaired and sometimes hardly detectable in patients with Raynaud's phenomenon. Sildenafil
led to a more than 400 percent increase of flow velocity."

Medications that "thin" the blood, such as low doses of aspirin or dipyridamole (Persantine), are
sometimes helpful.

Some patients with persistent symptoms can benefit by adding a medication called pentoxifylline
(Trental) which makes the red blood cells more pliable, thereby improving circulation.

Oral medications may be prescribed, such as epoprostenol (a prostaglandin) or a drug that affects
the nerves (selective serotonin reuptake inhibitor), such as fluoxetine. Fluoxetine, a selective serotonin
reuptake inhibitor and antidepressant medication, may reduce the frequency and severity of
episodes.

Care of the nails must be done carefully to avoid injuring sensitive toes and fingertips. Ulcers on
the tips of the digits should be monitored closely by the doctor. These can become infected. Gently
applied finger splints are used to protect ulcerated areas. Skin creams or ointments that open the blood vessels
are sometimes used on the sides of severely affected digits to allow increased blood supply and help heal skin
sores. Topical nitroglycerin paste, which helps to dilate blood vessels, may be used
as needed to treat or prevent active Raynaud's disease. Apply the paste carefully as it can lead to
low blood pressure (hypotension) if used on large areas.

LIFESTYLE CHANGES

Patients with Raynaud's phenomenon who have no symptoms other than the color changes of extremities
may require only measures to prevent complications. Prevention measures are important in primary and
secondary RP regardless of the severity. Most of the lifestyle changes that help people with Raynaud's
aim to avoid the triggers of attacks. These triggers include cold, emotional stress, and certain medicines,
chemicals, or actions.

To protect the body from cold, people can:

Wear a hat, gloves, scarf, and a coat with snug cuffs during cold weather.

Wear gloves or mittens when taking food out of the refrigerator or freezer.

Turn down air conditioning, or dress warmly while in an air conditioned space.

Warm up the car before driving in cold weather.

To avoid emotional triggers, people can steer clear of stressful situations if possible. Relaxation
techniques also can be helpful under stress.

Limit frequent and repeated actions of the hands, such as typing or playing the piano.

A number of medicines can trigger attacks. See the provided links for other treatment options besides
using attack triggering drugs for a health problem. People with Raynaud's should avoid:

Medications that can aggravate symptoms of RP by leading to increased blood-vessel spasm (narrowing
the blood vessels) include over-the-counter cold, allergy and weight-control preparations, such as
pseudoephedrine (Actifed, Chlor-Trimeton, Cotylenol, and Sudafed).

Mild cases of Raynaud's can be addressed by biofeedback or a technique to help control involuntary body
functions such as skin temperature and help to decrease the severity and frequency of RP in some patients.

Other helpful lifestyle changes for people with Raynaud's are those that boost blood flow in the body.
These include exercising regularly and quitting smoking. Direct and indirect (passive) smoking should
be avoided by patients with RP. The chemicals in tobacco smoke can cause blood-vessel constriction and
lead to atherosclerosis (hardening of the arteries), which can further impair oxygen supply to the extremities.

When attacks do occur, people with Raynaud's can take several steps to limit the length and strength
of the attacks. These steps include:

Compression of the blood vessels by tight-fitting wrist bands, rings, or footwear should be avoided.

Moving to a warmer spot, such as indoors during cold weather or relocating to a warmer climate.

Warming the hands or feet. Hands can be placed under the armpits, and feet or hands can be soaked
in warm water. Heatbands and hand warmers may be used on the wrists to warm the blood flowing to the hands.

Wiggling or massaging the fingers and toes.

Moving the arms in circles or shaking arms or feet.

Relaxing and getting out of or removing yourself from stressful situations that trigger the attacks.

Those with RP should guard their hands and feet from direct trauma and wounds. Any wounds or infections
should be treated early to prevent more serious infections. Anyone with Raynaud's who develops sores on
their fingers or toes or elsewhere on their body should see a health care provider right away to prevent tissue loss.

SURGICAL INTERVENTION

More serious cases require medical intervention due to the risks of gangrene and possible digital amputation.
Microvascular surgery of the affected areas is a possible therapy.

The rare patient who develops sores or tissue death (gangrene) needs more aggressive treatment. Such
treatment includes antibiotics and surgery to cut out damaged tissue. People with severe, worsening
Raynaud's may have surgery or shots to block the action of nerves in the hands and feet that control
blood flow in the skin. This surgery often gets rid of symptoms for 1-2 years. Patients may need
shots more than once.

Severe cases of Raynaud's phenomenon can lead to gangrene and the loss of digits. In rare cases of severe disease,
nerve surgery called "sympathectomy" is sometimes considered. In this procedure, to prevent blood-vessel spasm,
the nerves that signal (stimulate) the constriction of the blood vessels (sympathetic nerves) are surgically
interrupted (surgically cut). Usually, this is performed during an operation that is localized to the sides of the
base of the fingers at the hand. Through small incisions the tiny nerves around the blood vessels are
stripped away. This procedure is referred to as a digital sympathectomy.

In intractable cases, sympathectomy and infusions of prostaglandins, e.g. prostacyclin, may be tried,
with amputation in exceptionally severe cases.

RESEARCH

Researchers have reported finding a substantial genetic (inherited) contribution both to the symptoms of
Raynaud's phenomenon and to the associated blood-vessel changes of patients with Raynaud's phenomenon.

Other researchers are studying nitric oxide and its potential relationship to Raynaud's phenomenon.
A gel is being studied which might promote local production of nitric oxide in involved digits. The local
nitric oxide, it seems, may open the blood vessels and improve the impaired circulation.

LIVING WITH RAYNAUD'S DISEASE

Primary and secondary Raynaud's are conditions that may be lifelong. Most people with primary
Raynaud's respond to simple lifestyle changes or medicines. Such treatment is not always as
successful in secondary Raynaud's. If you have secondary Raynaud's, you may find that in time your
medicines are less effective and your attacks become more frequent and/or more severe. Switching to a
new treatment may help relieve or prevent your symptoms. Be sure to seek a health care provider's care if you
develop sores on your fingers or toes or elsewhere on the body. Follow the lifestyle suggestions recommended
above to help prevent and reduce the frequency and intensity of attacks. Follow a healthy nutritional program
as recommended below.

PROGNOSIS

For most people, primary Raynaud's is more of a bother or an annoyance than a serious illness and it can
usually be managed with minor lifestyle changes. Secondary Raynaud's can be more difficult to manage, but
several treatments may help prevent or relieve symptoms. Among the most important treatments for
secondary Raynaud's is treating of the underlying condition.

Two separate gels combined on the fingertip (somewhat like two-part epoxy, they cannot be combined
before use because they will react) increased blood flow in the fingertips by about three times.
One gel contained 5 percent sodium nitrite and the other contained 5 percent ascorbic acid.
The milliliter of combined gel covered an area of approximate 3 cm2. The gel is wiped off
after a few seconds.

Biofeedback, which is a treatment technique in which people are trained to improve their health by
using signals from their own bodies, is another therapy for Raynaud's disease.

See the dietary and nutrition recommendations found in the Nutrition links below for more information and
consult with a health care provider and/or a nutritional therapist to help you treat any underlying disorders.

If white finger (Raynaud's), occurs unexpectedly and a source of warm water is available allow tepid
to slightly warm water to run over the affected digits while gently massaging the area. Continue this
process until the white area turns pink or a normal healthy color.

If triggered by exposure in a cold environment, and no warm water is available, place the affected
digits in a warm body cavity - arm pit, crotch, or even in the mouth. Keep the affected area warm at
least until the whiteness returns to pink or a healthy color, avoid continued exposure to the cold.

HERBS

The extract of the
Ginkgo Biloba leaves may reduce frequency of Raynaud's attacks.

If you have problems developing abscesses for lack of proper circulation,
Goldenseal
made into a poultice can be directly applied to the abscess. Or apply alcohol-free Goldenseal Extract to
sterile gauze and place the gauze over the abscess and to treat infection problems.

CAUTION! Do not take Goldenseal internally on a daily basis for more than one week at a time, and DO NOT USE IT
DURING PREGNANCY. If you have a history of cardiovascular disease, diabetes, or glaucoma, use it only under
a health care provider's supervision.

Milk Thistle, taken in capsule form, is good for the liver and aids in cleansing the bloodstream.

Tea Tree Oil, applied externally, is a potent natural antiseptic that kills infectious organisms without
harming healthy cells. Mix 1 part tea tree oil with 4 parts water and apply the mixture with a cotton ball 3
times daily. It will destroy bacteria, hasten healing, and prevent infection from spreading.

The following nutrients are important for healing once appropriate local treatment has been administered.
Unless otherwise specified, the following recommended doses are for those over the age of 18. For a
child between 12 and 17 years old, reduce the dose to 3/4 the recommended amount. For a child between
6 and 12 years old, use 1/2 the recommended dose, and for a child under 6, use 1/4 the recommended amount.

Information, supplements and products for Raynaud's Disease, a circulatory disorder that causes the fingers, toes
and other extremities to be overly sensitive to cold. Also included are supplements and products helpful for
treating infection and gangrene, which can result due to chronic vessel constriction and tissue damage.

Promotes healthy circulation, useful for arthritis and cardiovascular & respiratory support. It also
supports digestion and is a natural remedy for ulcers. Garlic is known to lower cholesterol naturally.

Chlorofresh is a special liquid chlorophyll complex, derived from premium alfalfa leaves. Chlorofresh is used
chiefly as an aid to reduce odor from a colostomy or ileostomy and to reduce fecal odor due to incontinence.

A coenzyme for several key steps in the production of energy within each cell, and an antioxidant important
in its clinical effects. It is these two properties make CoQ10 one of the best supplements available today.

NOW Foods DMG Supplement is a methylated amino acid found in all cells. DMG is an antioxidant and methyl
donor that has a number of beneficial effects. It has shown to have potential in increasing immune response
to the flu and salmonella.

Garlic oil is often used to soothe the ear and as an antibiotic but most often used as a food and herb
and also to lower serum cholesterol and blood pressure and to improve circulation as well as possibly
inhibiting the growth of ulcer causing bacteria.

Niacin or vitamin B-3, is necessary for normal breakdown of fats and fatty acids and the release of energy
from carbohydrates. It is also an excellent vasodilator and may be useful in maintaining proper cholesterol levels.

You notice symptoms suspicious for Raynaud's disease. Further testing may be needed to see if
you might have another medical condition that is causing your symptoms.

KEY POINTS

Raynaud's is a rare disorder that affects blood flow to the fingers and toes, and rarely affects other
areas such as the nose, ears, nipples, and lips.

When Raynaud's occurs without any known cause, it is called primary Raynaud's. When a cause can be
identified, the disease is called secondary Raynaud's.

People with Raynaud's have attacks in response to cold or emotional stress. During these attacks,
their fingers, toes, or other extremities temporarily pale and/or become bluish due to a lack of
blood flow. As blood flow returns, the area turns red. The affected areas also may throb or feel cold,
numb, or tingly.

Raynaud's is usually diagnosed based on a history of symptoms, the exclusion of other conditions,
and certain diagnostic tests.

Common causes of secondary Raynaud's include other disorders, medicines, chemicals, or work conditions
that affect blood flow to the extremities.

Primary Raynaud's often can be managed with minor lifestyle changes. Secondary Raynaud's may require
changing or stopping certain medicines, treating any underlying conditions, and having surgery
(in severe cases).

People with severe secondary Raynaud's may develop sores or tissue death (gangrene) in the extremities.
This is uncommon.

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